Billions of dollars each year are allocated to research with the goal of improving the health of a population. Despite this, many health policies in place do not reflect the current science. Often, findings from basic, clinical, and health services research fail to be translated to policies and practice that may improve health. Scientists play a critical role in explaining their findings as part of the health policy process. For proper dissemination, implementation, and adoption, scientists must not only conduct rigorous science but also be able to communicate their work to the appropriate bodies to improve policy outcomes as well as population health.

The most-touted success story of translation of science to policy implementation is community water fluoridation. Although it has been met with some challenges, international and domestic policies have embraced community water fluoridation. The U.S. Centers for Disease Control and Prevention (2015) has listed “fluoridation of drinking water to prevent dental caries” among the “achievements in public health, 1900–1999.” Many communities have implemented water fluoridation programs, and dental caries rates have declined (American Dental Association 2005). Recently, the role of sugar in the dental caries process has garnered much attention. The association of diet, namely sugar intake, on the development of dental disease has been established, but what remains to be seen is how these findings will be translated to widespread policies to reduce intake.

 

The Science: Sugar and Dental Caries

In a systematic review commissioned by the World Health Organization (WHO), Moynihan and Kelly (2014) reported that a moderate level of evidence exists for the relationship between sugar intake and dental caries, particularly in children. The  investigators examined >50 studies using the Grading of Recommendations Assessment, Development, and Evaluation system for the review. They included multiple studies that found that those who consumed free sugars >10% of total energy intake had increased levels of dental caries when compared with those who had <10% free sugar intake. Nearly all the studies included reported a positive association between sugar intake and dental caries experience. The evidence of this association became apparent in the early 1950s and has been substantiated for >50 y in >20 countries. The dental caries process is dynamic and fluid by nature. Featherstone (2004) describes it as a “balance between pathological factors that lead to demineralization and protective factors that lead to remineralization.” Pathological factors mentioned are bacteria and ingestion of fermentable carbohydrates (sugars); protective factors include salivary flow and fluoride exposure. Caries reduction attributable to water fluoridation ranges from 8% to 37% among adolescents (Newbrun 1989). Topical fluoride therapies also have been shown to reduce caries by nearly 25% when compared with no fluoride therapy (Marinho et al. 2004).

Despite the widespread use of home and professional fluorides and community water fluoridation, dental caries continues to be a problem. Sheiham and James (2015) make the case for sugar being the primary and necessary factor of the dental caries process, emphasizing the cumulative effect of sugar consumption over a lifetime as it relates to dental caries. In a large longitudinal population study following children from birth to age 10, Ruottinen and colleagues (2004) compared caries status in children with high sugar consumption exceeding 10% of

energy intake with those below. They reported that those children in the low-sugar-intake group had on average 50% less disease experience (as measured by DMFT/dmft) than children in the high-sugar-intake group. Reducing sugar intake requires behavior change. Although much is known about the association of sugar intake and dental caries, there have been few longterm randomized clinical trials targeting behavioral changes to decrease sugar intake to date (Ebbeling et al. 2006). A systematic review examining sugar intake and weight gain/obesity

concluded that there was “moderate level evidence” but stressed that many of the randomized control trials addressing sugar and obesity in children suffered from poor compliance, which led to a finding of no effect (Te Morenga et al. 2013). This illustrates the difficulty in conducting research to elicit behavior change.

Journal of Dental ResearchSugar, Dental Caries, and Health Policy research-article2015 1Department of Pediatric Dentistry, School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA  2Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, NC, USA Corresponding Author: J.Y. Lee, UNC School of Dentistry, 228 Brauer Hall, Campus Box 7450, Chapel Hill, NC 27599, USA. Email: jessica_lee@unc.edu

The Policies: Limiting

Sugar Intake

Policies to promote behavior change can be categorized into 4 primary strategies: 1) provide information about the behavior, 2) increase/decrease opportunities for behavior, 3) provide incentives/disincentives for behavior, and/or 4) require/prohibit behavior (Dunton et al. 2010). All 4 approaches have been applied, with variable success, in attempts to reduce sugar intake. The WHO (2015) recently published guidelines calling for restricted sugar intake based on evidence relating sugar to higher risks of noncommunicable diseases—namely. unhealthy weight gain and dental caries. The guidelines were created to set recommendations for policy makers looking to reduce the risk of these 2  noncommunicable diseases in adults and children. The new WHO guidelines include 1) a strong recommendation to reduce free sugar intake over the course of a lifetime, 2) a strong recommendation to limit free sugar intake to <10% of total energy (calories) consumed, and 3) a conditional recommendation to reduce the free sugar intake to <5% of total energy intake.

The recommendations developed by WHO are in place to protect the health of populations while understanding that individual differences may exist. In light of this, it suggests that these guidelines should not apply to those in need of specific therapeutic diets but rather be used by policy makers to develop policies consistent with national nutritional guidelines and cultural norms. The WHO recommendations are by no means calling for a zero-tolerance policy on sugar intake; rather, they are simply calling for a reduction in sugar intake that could improve the health of populations. Policy recommendations to limit sugar intake are certainly not new. In 2010, the U.S. Department of Agriculture and the U.S. Department of Health and Human Services jointly released the revised dietary guidelines. In it, they report that “added sugars contribute an average of 16 percent of the total calories in American diets,” and they make a recommendation that the total amount of added fats and sugars consumed be reduced to 9% to 15% (depending on total caloric intake) for an average adult. The 2015 guidelines are currently being developed and have been open for public comment. The draft guidelines include a reduction in added sugar intake to no more than 10% of daily energy. It also supports labeling and educational approaches, including added sugar labeling (U.S. Department of Agriculture and U.S. Department of Health and Human Services 2015). The American Dental Association (2015) was among many organizations that provided public comment in support of the dietary restrictions on added sugar intake. Other health policy approaches have been implemented to reduce sugar intake (Figure). In efforts to educate the public about nutritional content in packaged foods, the U.S. Congress passed the 1990 Nutrition Labeling and Education Act, which authorized the U.S. Food and Drug Administration to require that all packaged foods label the amount of nutrients, including sugars. In 2014, the U.S. Food and Drug Administration proposed a rule change to require a declaration of “added sugars.” Collectively, the recent policy changes should have some impact on sugar intake, but awareness raising and recommendations for intake restrictions are not often enough to prompt behavior change. More attention is needed to address the accessibility of sugary products (i.e., access to vending machines) and disincentives for behavior (i.e., sugar tax).

 

The Challenges: Translating

Science to Policy

Despite the existing scientific evidence showing that increased intake of sugar is associated with dental caries, very little action has taken place to address these issues at the policy level. Research has identified several factors that may hinder the translation of research into health policy. Factors include the perceived need of researchers to be objective and their balancing objectivity with advocacy and an ability to communicate research findings to stakeholders and policy makers (Brownson

et al. 2009). Sommer (2001) argues that “standing by the sidelines pursuing other interests and expecting published data to ‘speak for itself’ is leaving a good deal to chance.” Scientists can and should be very useful to policy makers. Other major barriers to implementation may involve outside parties with special interests. Kearns and colleagues (2015) gave historical context to the discussion surrounding

sugar intake and dental caries. In their investigation, the authors reviewed the sugar research organizations’ efforts to influence not only public awareness but also research agendas and policy decisions dating back to the early 1950s. A case study by Parascandola (2005) reviewed the relationship among science, industry, and policy related to tobacco harm reduction and found that tobacco interest groups were primarily focused on protecting their interests and assets rather than contributing to a growing knowledge base. Clearly, opposition to translating science to public health policy is not new. In the early 1950s, the first opposition to water fluoridation arose, and some still continues today (Richmond 1985). A major challenge in health policy making is creating policy that satisfies key stakeholders while being true to the research and promoting population health.

 The Future

As the policies surrounding limiting sugar intake continue to evolve, attention must be given on how to best put these polices into practice to produce positive behavior change, which ultimately should lead to improved oral health outcomes. Future research need not focus on the specifics of the restriction but instead on the behavioral changes required to adhere with the recommendations. Moving forward, perhaps policy makers could be courageous enough to develop policies restricting sugar intake consistent with national and WHO guidelines, and maybe researchers can begin to uncover the behavioral keys necessary for the successful implementation of these policies.

In 2005, the National Institute of Dental and Craniofacial Research awarded 3 major grants that establish regional “practice- based” research networks to investigate with greater scientific rigor everyday issues in the delivery of oral health care. Recently this has been transformed into a National Dental Practice–Based Research Network. This may provide a forum to conduct behavior research on sugar intake. In 2006, the National Institutes of Health launched the Clinical and Translational Science Award (CTSA) program. The goal of the CTSA is to accelerate “the process of translating laboratory discoveries into treatments for patients, training a new generation of clinical and translational researchers, and engaging communities in clinical research efforts.” The CTSA could also be a mechanism to test policies on sugar intake. There has been increasing attention on how to reduce the research, evidence-practice, and policy gaps. Translational research traditionally describes how basic biomedical sciences can be incorporated into clinical practice, but the additional step of translation of clinical science into improved health must also occur. This requires engagement of stakeholders (policy makers, insurance companies, private sector, etc.) who are in the appropriate positions to use the evidence to make informed policy decisions to improve the health of a population.

Author Contributions

B.D. Meyer, contributed to design, drafted and critically revised the manuscript; J.Y. Lee, contributed to conception, design, data acquisition, analysis, and interpretation, drafted and critically revised the manuscript. Both authors gave final approval and agree

to be accountable for all aspects of the work.

 

Acknowledgments

The authors received no financial support and declare no potential conflicts of interest with respect to the authorship and/or publication of this article.

 

References

American Dental Association. 2005. Fluoridation facts. Chicago (IL): American

Dental Association Council on Access, Prevention, and Interprofessional

Relations.

American Dental Association. 2015. ADA supports dietary guidelines on added

sugars. ADA News. 46(10):1.

Brownson RC, Chriqui JF, Stamatakis KA. 2009. Understanding evidencebased

public health policy. Am J Public Health. 99(9):1576–1583.

Centers for Disease Control and Prevention. 2015. Ten great public health

achievements in the 20th century [accessed 2015 Jun 13]. http://www.cdc

.gov/about/history/tengpha.htm.

Dunton GF, Cousineau M, Reynolds KD 2010. The intersection of public policy

and health behavior theory in the physical activity arena. J Phys Act

Health. 7 Suppl 1:S91–S98.

Ebbeling CB, Feldman HA, Osganian SK, Chomitz VR, Ellenbogen SJ,

Ludwig DS. 2006. Effects of decreasing sugar-sweetened beverage consumption

on body weight in adolescents: a randomized, controlled pilot

study. Pediatrics. 117(3):673–680.

Featherstone JB. 2004. The continuum of dental caries—evidence for a dynamic

disease process. J Dent Res. 83 Spec Issue C:C39–C42.

Food and Drug Administration. 2014. Food labeling guidelines [accessed 2015

Jul 14]. http://www.fda.gov/food/guidanceregulation/guidancedocuments

regulatoryinformation/labelingnutrition/.

Kearns CE, Glantz SA, Schmidt LA. 2015. Sugar industry influence on the scientific

agenda of the National Institute of Dental Research’s 1971 National

Caries Program: a historical analysis of internal documents. PLoS Med.

12(3):e1001798.

Marinho VC, Higgins JP, Sheiham A, Logan S. 2004. Combinations of topical

fluoride (toothpastes, mouthrinses, gels, varnishes) versus single topical

fluoride for preventing dental caries in children and adolescents. Cochrane

Database Syst Rev. 1:CD002781.

Moynihan PJ, Kelly SM. 2014. Effect on caries of restricting sugars intake:

systematic review to inform WHO guidelines. J Dent Res. 93(1):8–18.

Newbrun E. 1989. Effectiveness of water fluoridation. J Public Health Dent.

49(5 Spec No):279–289.

Parascandola M. 2005. Science, industry, and tobacco harm reduction: a case

study of tobacco industry scientists’ involvement in the National Cancer

Institute’s Smoking and Health Program, 1964–1980. Public Health Rep.

120(3):338–349.

Richmond VL. 1985. Thirty years of fluoridation: a review. Am J Clin Nutr.

41(1):129–138.

Ruottinen S, Karjalainen S, Pienihäkkinen K, Lagström H, Niinikoski H,

Salminen M, Rönnemaa T, Simell O. 2004. Sucrose intake since infancy

and dental health in 10-year-old children. Caries Res. 38(2):142–148.

Sheiham A, James WP. 2015. Diet and dental caries: the pivotal role of free

sugars reemphasized. J Dent Res. 94(10):1341–1347.

Sommer A. 2001. How public health policy is created: scientific process and

political reality. Am J Epidemiol. 154(12 Suppl):S4–S6.

Te Morenga L, Mallard S, Mann J. 2013. Dietary sugars and body weight:

systematic review and meta-analyses of randomised controlled trials and

cohort studies. BMJ. 346:e7492.

U.S. Department of Agriculture, U.S. Department of Health and Human

Services. 2010. Dietary guidelines for Americans, 2010. 7th ed. Washington

(DC): U.S. Government Printing Office.

U.S. Department of Agriculture, U.S. Department of Health and Human

Services. 2015. Office of Disease Prevention and Health Promotion scientific

report of the 2015 Dietary Guidelines Advisory Committee [accessed

2015 Jul 14]. http://www.health.gov/dietaryguidelines/2015-scientificreport/

pdfs/scientific-report-of-the-2015-dietary-guidelines-advisorycommittee.

pdf

World Health Organization. 2015. Guideline: sugars intake for adults and children.

Geneva (Switzerland): WHO Document Production Services